Public education

Breast anatomy

From the anatomical point of view, the breast area expands a square-shaped region that begins from the top to the clavicle, from the bottom to the underwear strap, from the side to the line that is drawn down from the middle of the armpit cavity, and is limited from the inside to the sternum.

 

 

The breast is an organ that consists of milk-producing glands and milk ducts, and these glands and ducts are surrounded by fatty tissue and supporting tissues. The milk producing glands are located in groups and each group is called a lobe, which are approximately 15-20 lobes. Therefore, each lobe contains a large number of smaller glands in the shape of a bunch of grapes, which are responsible for producing milk. Therefore, when we touch the breast, we feel it piles and piles of glands. Milk ducts collect the milk produced inside each lobe and transport it outside each lobe.

Hence, there are 15-20 milk ducts that go directly from each lobe to the nipple and drain the milk out through the nipple openings.

Under the glandular tissue and fat of the breast, there are chest muscles on which the breast is placed. From the sheath covering these muscles, rope like structures go into the breast and after passing through the breast tissue, they stick under the skin of the breast. This causes the breast to remain fixed in a certain position on the muscles. These ropes are called Cooper's ligaments.

Introducing breast cancer

Our entire body is made up of cells. The cells are very small and can only be seen under a microscope. Normally, cells multiply to replace old and dead cells or, in children, to cause body growth. This proliferation of cells is subject to certain laws. Therefore, the cells increase as much as necessary, not less and not more. During the occurrence of cancer, the growth and proliferation of cells goes out of control and a large number of new cells are created, which gradually lead to the creation of a cancerous mass or tumor.

Breast cancer is almost a disease of women, although men are not excluded. Women make up more than 99% of sufferers. In terms of age, the occurrence of breast cancer is less common in people under 30 years old.

In Western countries, breast cancer is mainly seen in people over 50 years old, while according to studies conducted in our country, the number of patients in the age range of 40-49 years is more than other age groups. Also, the number of younger patients is more than in western countries.

Predisposing factors include old age, family history, infertility, first pregnancy over the age of 30, consumption of foods containing a lot of animal fat, etc. Many of these patients do not have many clinical symptoms in the early stages and the disease is determined by a surgeon's examination and mammography. In terms of the location of cancer in the breast, the most part of the breast that has the possibility of cancer is the outer upper quadrant of the breast.

In the early stages of the disease, the patient may be completely asymptomatic, and after being referred for control, the suspicion of cancer may arise in the patient, or this suspicion may be confirmed by diagnostic methods such as mammography or ultrasound. Sometimes the examining doctor does not find an important symptom in the patient, and by performing diagnostic methods such as mammography, the presence of a suspected cancer lesion requires follow-up and definitive diagnosis of the disease. Obviously, in these cases, the cancerous lesion is diagnosed in the early stages and its treatment will be more successful.

Breast cancer can be completely asymptomatic in the early stages. If the disease is diagnosed in these stages, its treatment will be much easier.

Breast cancer symptoms

1. Breast mass or tumor

A painless lump is the most common symptom of breast cancer, which is discovered by the patient in about 75% of cases by chance or during a monthly examination.

Considering that the mass can be seen in both benign and malignant diseases of the breast, it is better to see a doctor if you feel any lump in the breast for examination.

The characteristics of suspected cancer masses on touch are: firm consistency, immobile and with adhesion to the surrounding tissue. As mentioned, most of these lumps are single and painless.

2. Discharge from the nipple

Discharge from the nipple is usually caused by benign breast diseases. Although the presence of nipple discharge in most cases is not associated with breast cancer, due to the possibility of the presence of cancer along with this symptom, it is necessary to check it carefully.

The presence of discharge from both breasts and from multiple ducts is usually caused by a hormonal disorder, drug use, or diffuse fibrocystic changes. In these cases, examining the patient's hormones, taking history, taking medications and using different diagnostic methods according to the history and examination will be helpful. It should be noted that in multiparous women, the presence of a brief milky discharge It can exist in the breast for several years without any specific disease. Spontaneous discharge of blood from a breast and out of a duct is more likely to be associated with breast cancer and increases the suspicion of cancer.

According to the studies conducted in 5-20% of patients, unilateral breast discharge can be a sign of breast cancer and in other cases it can be a sign of one or more small benign lesions in the breast ducts (papilloma) or fibrocystic changes or Expansion of breast ducts.

Breast discharge can be seen in different colors (white, brown, blue, gray, red, green or colorless). The discharge caused by breast cancer is usually clear, bloody, or clear yellow blood.

Cytological examinations of breast secretions, which is usually performed, are not reliable for proving the presence of cancer. Old age and the presence of any mass with breast discharge raises the suspicion of cancer. The location of the duct from which the suspicious secretions come out is usually related to the location of the primary lesion, and often pressure on the same quadrant of the breast causes the secretion to come out. Sometimes, by using breast imaging with contrast material from the same duct (dactography), it is possible to find out the existence of a small lesion in that duct. If a lump with blood discharge from the breast is not palpable, it can indicate the presence of a lesion in the early stages.

Discharges that raise the suspicion of cancer:

* Bloody or watery secretions

* Secretions that come out spontaneously and without pressure

* Secretions that come out of a breast and a nipple duct

* Discharges that accompany the mass

* Postmenopausal secretions

It is very important that the discharge is bloody and comes out spontaneously, especially when it is accompanied by a mass and from a duct.

3. Breast skin changes

These changes are caused by indentation or stretching of the breast skin caused by cancer. As the cancerous tumor affects the tissue around it, it shortens the ligaments supporting the breast, and this change, in turn, creates depressions in the skin. The indentation of the breast skin may be permanently and distinctly present, or it may be seen in certain cases of breast examination. Stretching of the skin is not a definite finding indicating cancer and sometimes it is found after benign breast diseases.

In some cases, the adhesion of cancer tissue to the part under the skin causes a change in the shape of the breast. Changing the shape of the halo around the nipple can also be the reason for the presence of cancerous tissue under that part. Invasion of cancerous tissue to the skin may cause ulcers in the skin. Rarely, the presence of prominent and clear subcutaneous vessels in one part can also raise the suspicion of cancer. In advanced cases, the breast becomes stretched and thickened upwards. The presence of multiple skin lesions caused by cancer invasion is also a sign of the advanced stage of the disease. Swelling of the breast skin and characteristic changes of the orange skin in the breast are a sign of the deterioration of the disease, and swelling with warm redness with and without pain may be due to inflammatory breast cancer. This type of cancer can mimic the symptoms of infection and breast abscess and cause the patient and the doctor to make a mistake and the patient will undergo antimicrobial treatment for a long time. Sometimes, along with this inflammatory condition, a lump can be felt, but usually the breast becomes swollen and hard. In this case, a clear mass is not palpable. Despite the pain, redness and warmth in the affected breast, the patient does not have the general symptoms of infection, such as fever and chills. Invasion of the axillary lymph nodes occurs in the early stages of the disease.

4. Nipple changes

According to studies, about 30% of breast cancer patients show nipple involvement. Nipple involvement is more common in tumors that are located at 2 and a half centimeters in the nipple or are more than 2 centimeters in size. Clinically, two types of symptoms may appear: - Indentation of the nipple - Paget's disease of the nipple In some people, indentation of the nipple may occur after breastfeeding or after puberty without any specific symptoms, which can be reversed, but in cancer, this indentation is permanent, and with a careful examination of the breast, the presence of a mass under the nipple may be determined. . Paget's disease of the nipple is a type of breast cancer in which the nipple skin changes in the form of moist eczematous lesions

Redness and chronic itching of the nipple with scaling and cracking is a type of breast cancer called Paget's, unless proven otherwise.

5. Enlargement of armpit lymph nodes

About 70% of breast lymph is drained through the axillary lymphatic system, so the most common site of breast cancer invasion is the axillary lymph nodes.

Sometimes the size of the lymph nodes is accompanied by a clear mass in the breast, and sometimes a specific mass is not palpable. HoweverT, invasion of the underarm lymph nodes can also occur in cancer of other body organs such as lungs, ovaries, liver, kidney, and stomach, but breast cancer is the most common cause of invasion of these glands.

In these cases, mammography and ultrasound are helpful for diagnosis, but a normal mammogram does not rule out the presence of cancer in the breast, and the patient should undergo additional diagnostic methods and appropriate treatment. Enlarged axillary lymph nodes may be the only sign of a specific breast cancer.

6. Change in breast size

Sometimes, due to the excessive size of the tumor in one breast, the breasts are out of symmetry and the breast on one side is clearly bigger than the opposite side. Of course, the size of two breasts in healthy people is not completely the same, but the size of one breast compared to the other side, which has recently been created, should be taken into consideration, and by performing an examination, it was ensured that there is no mass and the health of the breast. Sometimes, benign masses and large cysts also cause this asymmetry, which can be detected by examination and using diagnostic methods.

7. Unilateral swelling of arm and upper limb

Due to the invasion of cancer cells into the underarm lymphatic vessels and the blockage of the lymphatic path, the drainage of the lymph fluid of the upper limb is disturbed on one side and causes swelling of that limb. The patient presents with a feeling of swelling and heaviness on one side of the body, which can be painful or painless. With a careful examination of the patient, the presence of a cancerous mass can be confirmed. Occurrence of this symptom as the initial symptoms is rare and a sign of advanced disease.

Sometimes, some of these patients may be mistakenly diagnosed with rheumatism and receive inappropriate treatment. Therefore, a careful examination of the breasts is necessary if there is such a symptom.

8. Invasion to other organs (metastasis)

Sometimes breast cancer without specific symptoms in the breast shows symptoms in other organs, which may be bone pain in a specific location, respiratory symptoms following lung involvement, jaundice and other symptoms caused by enlarged liver, enlarged abdominal lymph nodes, symptoms Nervousness caused by mass in the brain etc.

In these cases, careful examination of the patient and diagnostic tests can determine the presence of the disease in the breast. Sometimes, the main focus of the disease is not identified, and only by specific evaluation of the symptomatic organ, the invasion of cancer to that part is confirmed. These cases also require their own treatment.

Breast cancer definitive diagnosis methods

There are several diagnostic methods for examining suspected cancerous tumors in the breast. These methods, which are sometimes used alone and sometimes together for diagnosis, mainly include sampling or biopsy, photography or mammography, ultrasound and examination. The only method that definitively diagnoses breast cancer is sampling or biopsy, in which part or all of a tumor is removed from the breast and examined under a microscope. Sampling is done by a surgeon and examined by a microscope by a pathologist.

Biopsy may be performed surgically. In this way, depending on the size of the tumor and the condition of the patient, using local anesthesia or general anesthesia, an incision is made on the tumor site in the breast, the entire tumor or a part of it is removed, and then the incision site is sutured. Then the obtained sample is sent to the pathology laboratory. One day after this operation, the patient is able to do his daily work, only for a few weeks after that, he should not lift heavy objects with the hand of the sampled side. The wound will usually heal in less than 10 days.

There are other methods for sampling, including needle sampling, which is now widely used. In this method, under local anesthesia, with a very small incision, the skin is opened and several samples of the mass are removed by special needles called core. This method is very easy and effective, and almost all necessary tests are possible on the samples obtained from it.

Sometimes biopsy is done from the beginning in the operating room. In cases where the probability of the tumor being cancerous is high and other diagnostic methods such as mammography have also raised the possibility of malignancy, some doctors prefer to take the patient to the operating room and send an immediate sample to the laboratory under general anesthesia, and if If the answer indicates cancer, the breast removal operation is performed at the same stage.

Imaging techniques including mammography, ultrasound, ductography, and MRI are of special importance in breast cancer diagnosis.

Risk factors in breast cancer

Breast cancer is the most common female cancer in the whole world. According to the statistics of the World Health Organization, the incidence of this disease is increasing. Although the exact cause of this disease is not yet known, it seems that some women are more likely to get this disease. The known risk factors for breast cancer are: family history of breast cancer in first degree relatives, reproductive period factors such as early puberty, late menopause, age at first delivery more than 30 years old, not giving birth, not breastfeeding, socioeconomic factors, obesity After menopause and consuming a lot of fat, radiation to the chest and some benign breast diseases.

Possessing any of the above factors does not mean that you will definitely get breast cancer. Rather, its meaning is that you are slightly more at risk of contracting this disease than the general population of women (without risk factors), so you should use early detection programs under the supervision of a doctor.

Family history of breast cancer

Among the factors known to increase the risk of breast cancer, family history is considered one of the most important factors. About 5 to 10 percent of breast cancers are caused by a family history, and it is estimated that 20-30 percent of women with breast cancer have at least one family member suffering from breast cancer.

Medical studies have shown that in women whose family members (mother, sister, daughter) were diagnosed with breast cancer, there is a risk of developing this disease at a younger age, and bilateral breast cancer is more common in them.

On the other hand, women who develop breast cancer at a younger age, their first- and second-degree relatives are at a higher risk of developing breast cancer. Among the characteristics of breast cancer with a family background, the onset of the disease at a young age, the high incidence of the disease bilaterally, and the association of breast cancer with cancers of other organs such as the ovary.

The conditions that prove the presence of genetic predisposition in a woman are:

1. Many people in the family have a type of cancer
2. Diagnosing cancer at a younger age than the expected age for that type of cancer
3. Diagnosing two or three types of cancer in one person
4. Bilateral or multifocal cancer in one person
5. Having breast cancer in a male member of the family

Breast cancer at a young age is the most important feature of family susceptibility to cancer. When the existence of genetic predisposition in the members of a family is suspected, medical consultation and necessary investigations should be done to obtain more complete information to prove this predisposition.

In case your mother, sister or daughter had breast cancer, the probability of getting this disease is a little higher than normal people and it is better to use early detection programs under the supervision of a doctor.

If the presence of this genetic predisposition is proven in a woman and that woman is covered by early detection programs, in case of cancer, her disease will be discovered in the early stages and her life expectancy and quality of life will increase.

Factors related to the reproductive period and hormones

The risk factors of the reproductive period include the following:

• Premature menstruation and late menopause
• Pregnancy status:

1. Age of first pregnancy over 30 years

2. Infertility and not having children

• Use of contraceptives in certain circumstances
• Hormonal treatments after menopause
• No history of breastfeeding children

Premature menstruation and late menopause

Early menstruation and late menopause increase the risk of breast cancer. Many studies have shown that the age of puberty below 12 years compared to the age of puberty above 15 years, increases the risk of breast cancer by 2 times. In fact, any factor that increases the body's contact with estrogen increases the risk of breast cancer. The limited studies conducted in Iran in this field have not found a relationship between the age of onset of menstruation before the age of 12 and breast cancer. However, more extensive studies should be done to make a definitive statement.

Menopause age of more than 55 years also increases the possibility of breast cancer. Women who naturally go through menopause after age 55 are twice as likely to develop breast cancer as women who go through menopause before age 45.

Also, the possibility of getting the disease is reduced in women who have removed both of their ovaries before the age of 40 or have lost the hormonal activity of the ovaries for any reason.

Family history of breast cancer

Among the factors known to increase the risk of breast cancer, family history is considered one of the most important factors. About 5 to 10 percent of breast cancers are caused by a family history, and it is estimated that 20 to 30 percent of women with breast cancer have at least one family member with breast cancer.

Medical studies have proven that in women whose first-degree relatives (mother, sister, daughter) were diagnosed with breast cancer, there is a risk of developing this disease at a younger age, and bilateral breast cancer is more common in them.

On the other hand, women who develop breast cancer at a younger age, their first- and second-degree relatives are at a higher risk of developing breast cancer. Among the characteristics of breast cancer with a family background, the onset of the disease at a young age, the high incidence of the disease bilaterally, and the concomitant of breast cancer with cancers of other organs such as the ovary.

The conditions that prove the presence of genetic predisposition in a woman are:

1. Many people in the family have a type of cancer
2. Diagnosing cancer at a younger age than the expected age for that type of cancer
3. Diagnosing two or three types of cancer in one person
4. Bilateral or multifocal cancer in one person
5. Having breast cancer in a male member of the family

Breast cancer at a young age is the most important feature of family susceptibility to cancer. When the existence of genetic predisposition in the members of a family is suspected, medical consultation and necessary investigations should be done to obtain more complete information to prove this predisposition.

If your mother, sister or daughter had breast cancer, the probability of getting this disease is a little higher than normal people and it is better to use early detection programs under the supervision of a doctor.

If the presence of this genetic predisposition is proven in a woman and that woman is covered by early detection programs, in case of cancer, her disease will be discovered in the early stages and her life expectancy and quality of life will increase.

Pregnancy status

Age of first pregnancy

First of all, it is necessary to mention that the meaning of pregnancy here is the full period of 9 months of pregnancy, regardless of whether it leads to the birth of a live baby or not.

Age above 30 years at first pregnancy increases the risk of breast cancer. On the other hand, when the age of the first pregnancy is lower, the risk of breast cancer is lower. The importance of young age at first delivery is due to the early maturation of breast tissue, which reduces its sensitivity to carcinogens.

Therefore, if your first pregnancy and delivery was after the age of 30, it is better to pay more attention to the health of your breasts.

Childlessness and infertility

Not having children increases the risk of breast cancer. The risk of infection in childless women is similar to the risk of infection in women whose first childbearing age is more than 30 years.

If you have an infertility problem, especially if this problem is due to your hormonal disorders, it is better to be covered by early diagnosis programs.

Use of contraceptives

Previous studies have shown that there is a small relationship between the use of birth control pills and an increased risk of breast cancer. Subsequent investigations evaluated the effect of these drugs in two groups of women: the first group of young women who had used these drugs for a long time, and the second group, women who used these pills before their first pregnancy.

According to the results of many studies, taking these drugs for 4 years or more before the first pregnancy in young women increases the risk of breast cancer, and these effects may persist up to 10 years after use, although these results are still debated.

Due to the low prevalence of contraceptive pill use in the last 30 years, the information available in this field is not complete and more studies are needed.

Hormonal treatments after menopause

This type of treatment is a drug treatment to replace the natural ovarian hormones during menopause. At present, estrogenic and progesterone compounds are used after menopause to prevent menopausal complications. In many women after menopause, a combination of these two hormones is prescribed as hormone replacement therapy.

Every menopausal woman has her own conditions and must be under the supervision of her doctor for hormonal treatment. So:

Avoid any arbitrary use of hormonal drugs.

Never accept recommendations for hormone therapy from friends and acquaintances without consulting your doctor.

Hormone replacement therapy has the following benefits:

1) Reducing cramps and night sweats after menopause

2) reducing the dryness of the genital tract

3) relief of fatigue and mood changes caused by menopause

4) Elimination of sleep disorders

5) Removal of some degrees of urinary incontinence

6) Reducing mortality from heart diseases

7) Prevention of osteoporosis

Does hormone therapy increase the risk of breast cancer?

Hormone therapy increases the risk of breast cancer by 30%. Its benefits depend on the risk of breast cancer and other factors determined by the doctor. Your doctor examines you for the presence of breast cancer risk factors and decides to prescribe or not to prescribe these hormones according to the advantages and disadvantages of this method.

Factors that should be checked by the doctor:

1) History of breast cancer in the person or in the person's relatives

2) History of heart problems and blood pressure

3) History of coagulation problems

4) History of gallbladder disease

The most important factor in this issue is checking the history of breast cancer. If the patient has a previous history of breast cancer or if there is a history of the disease in his relatives, he must inform the doctor before appearing any problem in his final decision.

Also, the history of heart disease and high blood pressure, or the existence of a family history of these diseases, are very important factors that should be reported to the treating physician. If a person has a history of the mentioned cases, he must inform the treating doctor exactly so that the doctor can make a final opinion on the advantages and disadvantages of hormone treatment.

People who undergo hormone replacement therapy should use breast cancer early detection programs, in this case, the use of replacement hormones does not increase the risk of death from breast cancer.

History of breastfeeding children

Breastfeeding, as a protective factor against breast cancer, reduces the risk of developing this disease. It seems that the effect of breastfeeding does not depend on its duration and time. The supportive effect of breastfeeding is more obvious in premenopausal breast cancer. It is said that the longer the duration of breastfeeding, the stronger the protective effect, especially if the duration is longer than 6 months.

However, the lack of milk or its non-secretion in some women, which has led to the reduction of the breastfeeding period to less than 6 months, has no effect on the occurrence of breast cancer. Also, stopping milk by using hormonal drugs does not increase the risk of breast cancer, but if the mother's age at the time of breastfeeding is lower, this protective effect will be greater. However, since breastfeeding is not very common among western mothers, this issue requires wider investigations in our own country.

How can we reduce the risk of breast cancer?

Those who have a history of breast cancer in one of their relatives cannot change this factor.

People who have early menstruation or late menopause cannot change this factor.

But these people can reduce the effect of other risk factors by taking the following measures:

• Weight adjustment in proportion
• Reducing dietary fat
• Do daily exercise regularly
• Not using hormones after menopause

Some of the risk factors of breast cancer are controllable and with a little care, these factors can be controlled.

Role of environmental pollution in the occurrence of breast cancer

There is evidence that environmental factors and pollution can affect the incidence and mortality of breast cancer. Here we examine some environmental factors that can be effective in the occurrence of breast cancer:

Exposure to radiation

Health studies have proven that breast tissue exposure to radiation is associated with an increased risk of breast cancer. This effect has also been identified in young women who survived the atomic bombing.

This issue has also been reported in women who have repeatedly undergone chest x-rays or who undergo ionizing radiation treatment (radiotherapy) due to upper body cancers.

Increasing the risk of disease following high radiation exposure also depends on the patient's age, and the younger the patient is, the more likely this issue is (especially at the age of 10-30 years). The important thing is that performing mammography for the diagnosis of the disease or early diagnosis does not have such an effect, especially since it is mainly performed after the age of 35-40.

In the case of women who undergo chest radiotherapy due to unilateral breast cancer, an increased risk of breast cancer in the opposite breast has been reported, especially under the age of 45. Of course, there is a time interval of at least 10 years for the occurrence of breast cancer, which sometimes decreases. Although this probability is low. But it emphasizes the need to follow up patients with this disease after treatment.

Cigarettes and alcohol

Smoking is associated with many cancers. In some studies, smoking during adolescence and puberty, when breast tissue is more sensitive to carcinogens, has been associated with an increased risk of breast cancer. Also, an increase in risk has been seen in people who have been exposed to cigarette smoke, and the reason is that the smoke from burning cigarettes has more carcinogenic factors. Alcohol consumption also increases the serum level of estradiol, and the relationship between alcohol consumption and breast cancer has been observed.

Other factors

Accumulation of organochlorine toxins such as D.D.T in the body and exposure to electromagnetic fields in the work environment may be associated with an increased risk of breast cancer, but these effects are not 100% proven, and wider studies should be done to prove them.

Among the environmental pollutants that may increase the risk of breast cancer, exposure to radiation is considered the most important factor.

Compiled, written and translated by:

Dr. Ahmad Fazilat

Faculty member, Dept of Genetics, Motamed Cancer Institute, ACECR